IR 05000155/1993014
| ML20058P429 | |
| Person / Time | |
|---|---|
| Site: | Big Rock Point File:Consumers Energy icon.png |
| Issue date: | 10/14/1993 |
| From: | Jorgensen B, Phillips M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20058P422 | List: |
| References | |
| 50-155-93-14-EC, NUDOCS 9310250034 | |
| Download: ML20058P429 (17) | |
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i U.S. NUCLEAR REGUL* TOR * COMMISSION
REGION III
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Report No. 50-155/93014(DRP)
Docket No. 50-155 License Kc. DPR-6 Enforcement Action No.93-233 l
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Licensee:
Consumers Power Company 1945 West Parnall Road Jackson, Michigan Meeting Conducted: October 12, 1993 l
i Meeting At:
Region 111 Office, Glen Ellyn, Illinois
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Type of Meeting:
Enforcement Conference P
Inspection Conducted:
Onsite at Big Rock Poi,1 Nuclear Plant, i
August 24 througn Se:tember 14, 1993
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Inspectors:
R. Leemon i
C. Brown D. Desaulniers G. Bryan
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Reviewed By: [
/0 M. P. Phillips, Chief R>-
or Projects Section 23
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./k/y[f 2 Approved By:
,p B. L. Jorgefisen, Chief Date Reactor Projects Branch 2 t
Meetino Summary Enforcement Conference on October 12. 1993 P enri No. 50-155/93014)
Areas Discussed: The apparent violations and treas cf concern identified during the inspection were reviewed, and corrective ac;icns taken or planned by the
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licensee were discussed.
The enforceren o;;itns pertaining to the apparent
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violations were also discussed with the 'icer see.
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9310250034 931015 PDR ADDCK 05000155 G
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DETAILS
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Persons Present at Conference
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. Consumers Power Company-
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M. G. Morris, Executive Vice President, Chief Operating Officer _
- l D. P. Hoffman, Vice President, Nuclear Operations-l P. M. Donnelly, Plant Manager l
R. M. Rice, Director, Nuclear Performance Assessment _ Department (NPAD)
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G. C. Withrow, Safety and Licensing Director-i
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W. J. Trubilowicz, Operations Manager
M. Bourassa, Senior Licensing Engineer
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R. Flowers,-Shift Supervisor
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T. P. Horan, Senior Assessor, NPAD U.S. Nuclear Reaulatory Commission
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H. J. Miller,. Deputy Regional Administrator, RIII i
T. O. Martin, Deputy Director, Division'of-Reactor. Projects, RIII
M. P. Phillips, Chief, Reactor Projects'Section 2B,-RIII
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I. N. Jackiw, Project Engineer, Reactor Projects Branch 2, RIII l
C. H. Weil, Enforcement Specialist
B. A. Berson, Regional Consul, RIII
R. J. Leemon, Senior Resident Inspector, Big Rock Point
C. E. Brown, Resident Inspector,
- Rock Point
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K. G. O'Brien, Acting Enforcemen 3pecialist
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L. N. 01shan, Project Manager, NRR 2.
Enfor cent Conference
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An Enforcement Conference was held in the NRC Region III office on i
October 12, 1993.
This conference was conducted as a result' of the-i preliminary findings of the inspection conducted on August 24 through
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September 14, 1993, in which apparent violations of NRC regulations and
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license conditions were identified.
Inspection findings were documented
in Inspection Report No. 50-155/93015, transmitted to the. licensee by-i letter dated October 5, 1993.
The purpose of this conference was to (1) discuss the apparent violations, causes, NRC concerns, and the licensee's corrective actions; (2) determine t
if there were any escalating or mitigating circcmstances; and (3) obtain l
any information which would help determine the appropriate enforcement l
action.
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The licensee's representatives did not contest any of the apparent.
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the areas of concern, which are outlined in the NRC's handout provided at
the conference (Attachment 1). The licensee's representatives noted that t
the switching and tagging order had been prepared utilizing a copy of the
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appropriate piping and instrumentation drawing, which was new information.
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The licensee's representatives described the events which led to the
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apparent violations, including root causes and corrective actions taken I
and planned.
A summary of the licensee's corrective actions, a proposed
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errata sheet for the report, and a brief description addressing the
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escalation and mitigation factors were included in the attached handout i
that the licensee provided at the conference (Attachment 2). In addition
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to the short term corrective actions underway-to address the lessons i
learned from the associated events, longer term actions in the following
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areas were described:
improve communications links between Big Rock and
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Palisades to learn from each other, improve the corrective action system, l
provide physical aids to the control room to establish a clear picture of
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containment status, and increase the management commitment to backshifts
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during abnormal evolutions.
At the conclusion of the meeting, the licensee was informed that they
would be notified in the near future of the final enforcement action.
j Attachments:
As stated i
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U.S NUCLEAR REGULATORY COMMISSION
REGION III
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ENFORCEMENT CONFERENCE l-CONSUMERS POWER COMPANY BIG ROCK POINT OCTOBER 12,1993
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10:00 A.M. (CDT)
REPORT NUMBER 50-155/93015 EA NUMBER 93-233 REGION III OFFICE 799 ROOSEVELT ROAD, BUILDING 4 GLEN ELLYN, ILLINOIS l
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l LOSS OF CONTROL OF PLANT EVOLUTIONS
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CONTAINMENT INTEGRITY
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CONTAINMENT INTEGRITY LOST AND MODE
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CHANGED WITHOUT KNOWLEDGE OF SHIFT
SUPERVISION OR APPROVAL BY PLANT MANAGEMENT l
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SYSTEM PRESSURE TEST (HYDRO)
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PRIMARY SYSTEM OVERPRESSURIZED WHILE PERFORMING TEST RESULTING IN LIFTING SAFETY-
RELIEF VALVE AND RUPTURING FOUR RUPTURE DISKS
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SE_QUENCE OF EVENTS - CONTAINMENT SWITCHING & TAGGING ORDER (S&TO) 93-0375 DEVELOPED,AND
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REVIEWED BY TWO LEVELS OF SHIFT SUPERVISION WITH NO ONE IDENTIFYING CONTAINMENT BOUNDARY BREACH LOCAL LEAK RATE TEST OF FEEDWATER COMPLETED, S&TO RELEASED FOR IMPLEMENTATION, S&TO IMPLEMENTED (AT THIS POINT CONTAINMENT INTEGRITY LOST)
1-1/2 DAYS LATER SHIFT SUPERVISOR RELEASES CONTROL ROD
'?. iTilDRAWAL INTERLOCKS TEST FOR IMPLEMENTATION. THIS PROCEDURE REQUIRES PLANT CONDITIONS BE ACCEPTABLE FOR TEST -
ONE OF THE CONDITIONS WAS 'OK TO BE IN REFUELING OR RUN MODE' WilERE CONTAINMENT INTEGRITY IS REQUIRED
"URING 6 HOUR PERIOD, MODE SWITCHED CHANGED FROM COLD 311UTDOWN TO REFUELING ON SEVERAL OCCASIONS SUCH THAT IN REFUELING MODE A TOTAL OF 4-1/2 HOURS S&TO REMOVED, RESTORING CONTAINMENT INTEGRITY-4 LOSS OF CONTAINMENT INTEGRlTY RECOGNIZED, NEW S&TO ISSUED TO REESTABLISH CONTAINMENT, LER DEVELOPED AND SUBSEQUENTLY ISSUED l
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SEQUENCE OF EVENTS - HYDRO
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AFTERNOON OF 8/13 PRESSURIZATION UNDERWAY - SHIFT SUPERVISOR (SSI) HAS CV-4047 CLOSED TO STOP LEAKAGE THROUGli CLEANUP
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BLOWDOWN LINE VALVES. RECOGNIZES HYDRO TEST PROCEDURE REQUIRES BLOWDOWN BE AVAILABLE, BUT CONSIDERS IT AVAILABLE l
BECAUSE HYDRO PUMP OPERATOR (AO) AVAILABLE TO MANUALLY OPEN VALVE.
DURING LATER PART OF SHIFT REQUESTS VOLUNTEERS TO HOLD OVER
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FOR 11YDRO - NONE VOLUNTEER. AT 8:30 PM, HYDRO TEST PRESSURE I
REACHED AND STABILIZES.
SillFT SUPERVISOR OF ONCOMING SHIFT (SS2) ARRIVES EARLY TO DISCUSS llYDRO AND TURNOVER. SSI AND SS2 AGREE TO UTILIZE l
PUMP AO TO CONDUCT VISUAL CHECKS IN PLANT FOR LEAKS. SSI IIOLDS OVER SINCE NO VOLUNTEERS FOR TEST AND THERE IS NEED FOR VT2 QUALIFIED PERSONNEL.
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AT 00:15 SS2 CONDUCTS COMBINED PRE-JOB BRIEF AND SHIFT TURNOVER, WHICH IS RUSHED, LACKS DISCUSSION OF SOLID PLANT OPERATIONS AND FAILS TO INFORM AO OF HIS ABILITY TO M ANU ALLY OPEN CV-4047 VALVE TO ESTABLISH BLOWDOWN AO ARRIVES AT HYDRO PUMP, TAKES OVER SHIFT, AND OBSERVES STEADY PRESSURE AT PUMP HE THEN LEAVES TO LOOK FOR LEAKS.
WHEN HE GOES TO LOWER ACCUMULATOR ROOM, HE LEAVES RADIO AT PUMP CONTROL ROOM OPERATOR (CO) HEARS RELAY CLICK AND OBSERVES PRESSURE INCREASING AT A RATE OF ABOUT I PSIG PER 3 SECONDS.
HE WAITS AWHILE BECAUSE HE THINKS AO IIAS DONE SOMETillNG AT PUMP BEFORE ATTEMPTING TO CONTACT HIM. AS PRESSURE APPROACHES UPPER BOUNDARY OF TEST PRESSURE RANGE, CO M AKES l
SEVERAL ATTEMPTS BY RADIO AND PUBLIC ADDRESS SYSTEM TO
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CONTACT VARIOUS MEMBERS OF THE CREW IN CONTAINMENT TO DIRECT PRESSURE DECREASE.
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SEOUENCE OF EVENTS - HYDRO (Con 0 AO OBSERVES PRESSURE INDICATION IN-ACCUMULATOR ROOM
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OSCILLATING BETWEEN.1450 AND 1500 BUT DOESN'T CONTACT
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CONTROL ROOM.
l CHATTERING NOISE IS HEARD IN UPPER ACCUMULATOR ROOM, AO,-
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SS1, SS2, AND ANOTHER AO ALL RESPOND TO THIS AREA. SSl HAD-l LEFT HIS RADIO AT THE NEXT CONTAMINATED AREA HE WAS TO VISIT,-
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AND SS2 HAD STAGED HIS RADIO OUTSIDE THE STEAM DRUM AREA.
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AO PROCEEDS TO LOWER ROOM AND HEARS THE CO PAGE TO THE
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PLANT. HE YELLS UP TO SS2, WHO THEN CALLS THE_ CONTROL ROOM l
AND LEARNS OF RAPID PRESSURE INCREASE. HE THEN GOES TO PUMP l
AND THROTTLES DOWN REGULATOR, THUS REDUCING PRESSURE.
l WHILE DOING THIS, HE HEARS SOUND OF RELIEF LIFTING IN STEAM
DRUM AREA.
AFTER REGAINING CONTROL OF EVOLUTION, HYDRO TEST SUCCESSFULLY COMPLETED
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NRC CONCERNS / ROOT CAUSES
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LOSS OF CONTROL OVER PLANT EVOLUTIONS
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INADEQUATE ATTENTION TO DETAIL IN PREPARING TAGGING ORDER -
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(CONTAINMENT INTEGRITY)
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TENDENCY OF SHIFT SUPERVISION TO GET INVOLVED IN
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7'ROUBLESHOOTING - SSl AND SS2 BOTH FOCUS ON CHATTERING NOISE IN
ACCUhfULATOR AREA AND FAIL TO DETERhflNE STATUS OF THE TEST AND
PLANT CONDITIONS (HYDRO) OR MAINTAIN COhihfUNICATIONS WITH CONTROL ROOh!
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INADEOUATE WORK PLANNING
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FAILURE TO WALKDOWN/LOOK AT AFFECTED COMPONENTS TO.
l IDENTIFY EFFECT ON PLANT, RATHER ORDER PREPARED.AND REVIEWED AT TWO LEVELS WITHOUT IDENTIFYING CONTAINMENT i
BREACH (THIS ALSO IMPLIES LACK OF A QUESTIONING ATTITUDE ON
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THE PART OF REVIEWERS)
TEST SCHEDULED WITH SA1ALL NUh1BER OF V72 QUALIFIED PERSONNEL i
A VAILABLE l
t SHIFT SUPERVISOR HOLDS OVER AND IN HURRY TO LEA VE
INADEQUATE JOB BRIEFING - PREJOB BRIEFING CObfBINED WITH SHIFT l
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TURNOVER AND RUSHED, NO INFREQUENTLY PERFORhfED TASK BRIEFING, NO DISCUSSION OF SOLID PLANT OPERATIONS CONCERNS, NO DISCUSSION l
ON AVAILABILITY OF BLOWDOWN PATHWAY l
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DECISION AIADE TO CLOSE CV-4047 ELIMINATING BLOWDOWN POTENTIAL FROh! CONTROL R00A1 - DECISION BASED ON A VAILABILITY OF AO, HOWEVER, THIS IS NEVER COhiblUNICATED TO AO AND DECISION A1ADE TO
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si NRC CONCERNS / ROOT CAUSES (CONTINUED 1
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INADEOUATE COMMUNICATIONS
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SS's AND AO ABANDON RADIOS TO LOOK FOR LEAKS GAITRONICS SYSTEM FOUND INAUDIBLEllNOPERABLE AT SEVERAL
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LOCATIONS
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UPON NOTING OSCILLATING PRESSURES - FAILED TO CONTACT CONTROL l
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CONTROL ROOM PERSONNEL UNABLE TO CONTACT PERSONNEL IN PLANT.
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INADEOUATE WORK PRACTICES TAGGING ORDER IMPLEMENTED WITHOUT KNOWING IMPACT ON CONTAINMENT INTEGRITY AO EXPECTED TO CONTROL PRESSURE VIITHIN 50 POUND BAND USING A GA UGE WITH 200 POUND INCREMENTS
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NRC CONCERNS / ROOT CAUSES (CONTINUEDj
INADEOUATE OR WEAK PROCEDURES:
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SURVEILLANCE PROCEDURE DRAWING DOES NOT IDENTIFY
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CONTAINMENT BOUNDARY.
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CONTAINMENT ISOLATION SURVEILLANCE PROCEDURE DOES NOT IDENTIFY VFW-185 AS A CONTAINMENT ISOLATION VALVE
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CONTROL ROD INTERLOCK TEST PROCEDURE DOES NOT DESCRIBE
WHAT THE " ACCEPTABLE PLANT CONDITIONS" ARE
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BLOWDOWN PATHWAl' CONSIDERED "A VAILABLE" BUT COULDN'T BE UTILIZED DUE TO CLOSllRE OF CV-4047 i
NO CAUTIONS REGARDING OVERPRESSURIZATION WITH RUNNING PUMP i
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AND SOLID SI' STEM
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NO ACTIONS ON HOW TO HANDLE PRESSURE EXCURSIONS
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NRC CONCERNS / ROOT CAUSES (CONTINUEDL 6.
WEAK CORRECTIVE ACTIONS j
INADEQUATE ROOT CAUSE INVESTIGATION FOR PRIOR-LOSS OF
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CONTAINMENT EVENT - FAILED TO IDENTIFY CONTRIBUTING CAUSES -
LACK OF QUESTIONING ATTITUDE, NON-FORMAL CONTAINMENT-
ESTABLISHMENT l
INCOMPLETE CORRECTIVE ACTIONS FOR PRIOR LOSS OF CONTAINMENT
EVENT - ALTHOUGH SPECIFIED ACTIONS CALLED FOR A FLAG TO EXIST WHERE CONTAINMENT COULD BE BREACHED, THE IMPLEMENTED ACTIONS FOCUSED SOLELY ON EXISTING PROCEDURES, EVEN SO,
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CONTAINMENT ISOLATION SURVEILLANCE PROCEDURE STILL FAILED l
TO IDENTIFY A CONTAINMENT ISOLATION VALVE COMMONALITIES WITH PAST EVENTS-i INADEQUATE S&TO FOR FEEDWATER LINE ALMOST IDENTICAL TO EVENTS ASSOCIATED WITH 7/92 ENFORCEMENT CONFERENCE WHICH INCLUDED INADEQUATE S&TO FOR BATTERY CHARGER -
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THOSE CORRECTIVE ACTIONS NARROWLY FOCUSED CAUSES ASSOCIATED M7TH 1993 CONTROL ROD WITHDRAWAL EVENT AT PALISADES ALA10STIDENTICAL TO EVENTS ASSOCIATED WITH
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HYDRO EVENT - INADEQUATE JOB BRIEFINGS FOR BOTH,- TENDENCY '
OF SHIFT SUPERVISION TO GET INVOLVED IN TROUBLESHOOTING AND l
LOSE FOCUS ON THE OVERALL STATUS OF THE EVOLUTION,
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INADEQUATE COA 1AfUNICATIONS BETWEEN JOB SITE AND CONTROL
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ROOh!, INADEQUATE WORK PRACTICES IN THE PERFORA1ANCE OF THE
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TASKS.
j APPARENT LACK OF CONTRIBUTION FROM THE NPAD ORGANIZATION i
IN HELPING TO ENSURE THAT THESE TYPES OF EVENTS DO NOT OCCUR.
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SUMMARY BOTH EVENTS CAN BE ATTRIBUTED TO FAILURE ON THE PART OF SHIFT MANAGEMENT TO MAINTAIN AN AWARENESS OF OVERALL PLANT CONDITIONS, WITH A CONTRIBUTING CAUSE OF WEAK CORRECTIVE ACTIONS
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SUMMARY OF POTENTIAL VIOLATIONS 1.
CRITERION V: INADEQUATE INSTRUCTION (SWlTCHING AND TAGGING ORDER) - FAILED TO NOTE LOSS OF CONTAINMENT INTEGRITY, FAILED TO CONTAIN APPROPRIATE APPROVALS TO DEFEAT CONTAINMENT INTEGRITY (APPROVALS REQUIRED PER T.S. 3.6)
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T.S.6.8.1 : SHIFT MANAGEMENT APPROVED IMPLEMENTATION OF SWITCHING AND TAGGING ORDER TO BYPASS CONTAINMENT INTEGRITY WITHOUT BEING AWARE OF EFFECT OF ORDER ON STATUS OF PLANT Ill.
T.S.6.8.1 : SHIFT MANAGEMENT APPROVED IMPLEMENTATION OF
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CONTROL ROD BLOCK TESTING, WHICH REQUIRED PLANT STATUS BE ACCEPTABLE FOR REFUELING MODE, WHEN PLANT STATUS WAS NOT ACCEPTABLE (SUBSEQUENT PERFORMANCE OF TEST ALSO VIOLATED T.S. 3.6)
IV CRITERION V INADEQUATE CONTAINMENT ISOLATION PROCEDURE -
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FAILS TO IDENTIFY THE INBOARD FEEDWATER LINE DRAIN VALVE AS A VALVE REQUIRED TO BE CLOSED FOR CONTAINMENT ISOLATION
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V CRITERION XVI: INADEQUATE CORRECTIVE ACTION FOR SIMILAR 1992 VIOLATION INVOLVING INADEQUATE SWITCHING AND TAGGING ORDERS AND 1991 LER FOR BREACH OF CONTAINMENT INTEGRITY SYSTEM PRESSURE TEST L
T.S. 6.8.1 : FAILED TO MAINTAIN SYSTEM TEST PRESSURE BELOW 1535 PSIG WHEN FLANGE AND VESSEL WALL TEMPERATURES ABOVE 130 F 11.
CRITERION II: PERSONNEL INVOLVED I'N TEST DID NOT HAVE SUITABLE PROFICIENCY IN THE PERFORMANCE OF THE TEST - MOST PERSONNEL INVOLVED IN TEST WERE UNAWARE OF POTENTIAL FOR RAPID PRESSURE INCREASES CAUSED BY OPERATING A PUMP WITH A SOLID SYSTEM, AO LACKED KNOWLEDGE OF HOW TO MAKE BLOWDOWN PATHWAY AVAILABLE PER PROCEDURAL PREREQUISIT.
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ATTACHMENT 2
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CORRECTIVE ACTIONS
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MANAGEMENT DIRECTION
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Review IPTE Procedure engaging Engineering and NPAD Personnel.
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Review generic guidance in procedure and where specific evolutions require mandatory implementation of IPTE.
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Employee self-checking and feedback (STARR).
Implement self-checking for all other departments. This will foster improvement of
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Operations by making others involved. Also success of CPCo
employees suggestion program makes us believe this will work.
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Plant Expectations Stress requirement to personnel that one individual
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will be specified as the in-charge person and will have the
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primary responsibility for control of the evolution.
Stress direct communication with control room during
performance :f tests.
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Communications improvement between Palisades and Big Rock Point.
Establish a link between liPES efforts at Palisades and Big Rock
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Include NPAD in this program.
Man-Machine interface; fix pump and appurtenances (engineering
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looking at pressure protection on pump and gauge); fix PA System and
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perform PM
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Management Commitment to Backshifts during abnormal evolutions (refueling outages, all reactivity events, IPTE's...)
ROOT CAUSE EVALUATIONS j
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Develop HPES expertise (INP0 Training November 10, 11 and 12)
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Develop guidance when to use HPES
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Develop guidance for selection of CA evaluators to increase objectivity / independence. Also improve corrective action system i
OPERATIONS CONFIGURATION CONTROL
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Containment Control Physical marking / visual aid
Administrative Control
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Mode Switch Control Administrative Control
(Will look at the other areas for application based on the development of these two areas)
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i CORRECTIONS FOR:
INSPECTION REPORT NO. 50-155/93015 (DPR)
ENFORCEMENT ACTION NO.93-233 Tha following provides corrections that are considered to be factual corrections-
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Page 4 Section 2.A Last paragraph, the last sentence should read "about 2 full days" instead of "about 2 additional days".
Page 4 Section 2.B Second paragraph, the third sentence should reflect that the Shift Supervisor did use the P&ID's for his i
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review.
Page 6 Section 2.B Seventh paragraph, the fourth and fifth sentences j
should reflect that the self-checking program (STARR)
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is and was intended to be a global program for operations personnel.
It should be noted that the morning meeting and infrequently performed tests and
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evolutions I&TE program were also introduced.
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Page 7 Section 2.C First paragraph, the fourth sentence should indicate.
that the leak rate test procedure was completed by closing VFW-185, however as noted in Section 2.A second sentence, the operator immediately reopened the valve to implement the switching and tagging order.
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10 CFR 2 APPENDIX-C
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(April 30, 1992)
MITIGATION
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A)
Identification
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Containment Integrity -
Self-identified. Documented by LER.
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Hydro Overpressure -
Self-identified, however obvious due to RV relief (self-disclosing event)
Did not meet the threshold' for event reporting.
Both occurrences were not willful.
B)
Corrective Action Containment Integrity -
Reestablished containment integrity immediately upon recognition.
Extensive corrective actions proposed.
Hydro Overpressure -
Rapidly brought pressure back into conformance.
Extensive corrective actions proposed.
C)
Licensee Performance Believe performance is improving in the last year. New programs (IPTE and STARR) are helping and require adjustment / refinement as more experience is gained.
D)
Prior Opportunity to Identify The inspection report draws many similarities between previous events and the most recent ones. The root causes of the events are not similar in a specific sense. However there is generic similarity.
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Multiple Occurrences Neither is a multiple occurrence event in the same inspection period.
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Duration The hydro overpressure was immediately corrected. The containment integrity was breached for two days. However, it was only needed administratively for 4-1/2 hours. During this time the mode switch was moved but the reactor was not critical or intended to be critical. Any planned evolution that would have taken the reactor critical would have identified the containment breach.